Managing Human Error by Managing the Work Environment

Abstract This paper will discuss the role of human error in the incident causation process and indicate what the most effective means to identify and manage human error. Human is an important contributing cause in up to at least 90% of all incidents. Consequently the elimination of human error should be a most promising target for incident prevention. Human error prevention concentrates on systemic factors and the way in which management decisions can propagate into substandard conditions and actions at the work place. It attempts to help the organization to understand and control the incident causation process and not to focus mainly on the individual worker or the negative outcomes of incidents. Optimal control of the controllable workplace conditions that cause human error makes an organization maximally intrinsically safe. Managing these conditions is the next step in getting as close to zero incidents as economically and logistically feasible. Introduction Since the publication of Human Error (Reason, 1990) a consistent trend in the interest in the contribution of human error to industrial incidents can be noticed. The common factor in this trend is the theory that prevention of human error is most effectively gained by controlling the working environment instead of focusing on the individual who 'failed' (Cullen, 1990, Wagenaar, 1992). Safety does not, as many experts believe, depend on the number of sprinklers and hydrants installed, but a high proportion of incidents and catastrophes are the obvious result of management error (Brauner, 1991). According to Rasmussen (1998) incidents are the result of lack of control: 'A closer look at major incidents indicates that the observed coincidence of multiple errors cannot be explained by a stochastic coincidence of independent events. Incidents are more likely caused by a systematic migration toward incidents by an organization operating in an aggressive, competitive environment. Safety is a control problem.' World wide, a variety of different methods are utilized to reduce human error and conducting a Safety Culture Survey is one of them. To prevent human error a range of techniques are available, some more effective than others. So, why is a new approach to managing safety like conducting a Safety Culture Survey still necessary, with a whole new package of actions to be taken, if other initiatives as Incident Analysis, Unsafe Act Auditing, Qualitative Risk Assessment and Technical Safety Auditing are in place? In many companies these techniques are applied in an effort to improve safety performance. These techniques may be necessary but may not yet be sufficient to further decrease the number of incidents that the company is experiencing. Essential to improved safety performance is trying to improve the safety attitude of individuals at the workplace. Essential to this is to acquire insight into the situations that lead to incidents and how those specific situations can be avoided. These factors are not only present at the work floor but also at the supervisory and managerial levels. The most successful insights focus on the managerial responsibility in identification and elimination of adverse conditions at the workplace.